This project is predominantly based on a cross sectional self-administered mailed survey designed to address the type and frequency of ethical dilemmas faced by physicians, how they approach them, the types of ethical support they would find useful in addressing these ethical dilemmas, and their attitudes and practices in situations of scarce resources. The questionnaire was originally designed in English, piloted, translated into French, Norwegian, and Italian. Following IRB approval, the study sample included general practitioners and general internists from each of four European countries including England, Switzerland, Norway and Italy. In 2013 we revised the survey and administered it to a sample of physicians from Ethiopia to examine how ethical dilemmas related to bedside rationing from a developing country compare to those in developed, resource-rich countries that have already been surveyed. The principal investigator has also collaborated with non-NIH colleagues in using a similar survey among physicians across the US to determine their attitudes towards addressing costs in clinical practice. In addition, we are considering administering the survey in other resource-poor countries. The results of the European survey have been analyzed and six resulting peer reviewed journal articles have been published and two book chapters have been published. A book based on the research findings and commentaries from philosophers, physicians, and health policy experts was published by Oxford University Press in 2015. These publications report: 1. The ethical difficulties encountered in clinical Practice by European doctors. 2. Physicians access to ethics support services in the four European countries in the study. 3. The prevalence and determinants of physician bedside rationing in four European countries. 4. Physicians views on resource availability and equity in four European health care systems. 5. An examination of whether ethics consultants should help clinicians face scarcity in their Practices. The results of the Ethiopian survey have been analyzed and 3 papers have been published showing 1. The experiences of Ethiopian physicians which involve extensive resource scarcity, tough decisions and adverse consequences. 2. The criteria that Ethiopian physicians use in making resource allocation decisions 3. The extent to which Ethiopian physicians report a concern for providing financial risk protection to their patients. Results of the survey in the US have yielded valuable information about the attitudes of US physicians regarding their role and responsibilities in addressing health care costs.